002089 (RPL)P.O. BOX 1504 No. 002089
Building_ 78-105 CALLE ESTADO
Address 5239 Inw3 LA QUINTA, CALIFORNIA 92253
Owner -
BUILDING: TYPE CONST.- OCC: GRP.
Mailing "
AddressMW ? rK x !w A.P. Number
City Zip Tel. .
TIMIM �t 9226 568-2828, Legal Description
Contractor
��ss �{ 4 p�yp,��,,����u - Project Description
a Lie J. 1J6�i[iw'�i.i.G>`s
JM
Address
City .. Zip. Tel.... -
Cat. City 92234 328-2681
State Lic. City
& Classif. C53 Lic. # Si Sq. Ft. No. No. Dw.
Arch., E;ngr., Size Stories • Units
Designer New'p, Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION Y ~IDS n � in
I hereby affirm that I am licensed under provisions of Chapter9 jcommencing with Section
7000) of Divisioonj3 of the Businessgs`and-Prrooffe-ssion_s CCodb;fiand my license is.in full force and
effect.... I► �''yYf''.�— 7.f_•.,i
DATE _
OWNER -BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason:..(Sec. 7031.5,Business and Professions Code: Any city or county. which requires a 4! '>_ Ann M-
permit to construct, alter, improve, demolish, or repair any structure; :prior to its issuance also V v v AMOUNT
requires the applicant for such permit to file a signed statement that he is licensed pursuant to PERMIT' - -
the provisions of the Contractor's License Law, Chapter 9 .(commencing with Section 7000).0!
Division 3 of the Business and Professions Code, or that. he is exempt therefrom; and the basis •,
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant /or a permit Plan •Chk. Dep. i.
subjects the applicant to a civil penalty o/ not more than five hundred dollars ($500).
0 I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.. >�
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does -such work himself or through his own employees, Mech. .
Provided that such improvements, are not intended. or offered for,sale..If, however, the building
or improvement is sold within one year o/ completion, the owner•builder• will have the -burden Electrical
o/ proving that he did not build or improve for the purpose of sale.)-
❑ I, as owner of the property, am exclusively contracting with licensed contractorsto con- Plumbingnn
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law _
does not apply to an owner o/ property who builds or improves thereon, and -who contracts for S.M.I. -?{
such projects with a contractor(s) licensed pursuant to the Contractor's License Law:). -
Grading
❑ I am exempt under Sec..B. B. & P.C. for this reason
Driveway Enc.
Date owner Infrastructure
WORKERS' COMPENSATION DECLARATION
'I hereby affirm that I have a certificate of'consent to self:insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. , .❑ Certified copy is hereby furnished.. .
TOTAL? e_4#
CERTIFICATE OF EXEMPTION FROM REMARKS
- . WORKERS' COMPENSATION INSURANCE Pniril
(This section need not be completed i/ the permit is for one hundred dollars ($100) valuation B
or less.) . _
I certify that in the performance of thg work for which this permit is issued, I shall not F Y
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. I
^ALL GATV,
NOTICE TO APPLICANT. If, after making this Certificate o! Exemption you should become ZONE: A _ UL " c
ELF-cl AQ
subject to the Workers' Compensation provisions' of the Labor Code, you must forthwith Minimum Setback ING�
comply with such provisions or this permit shall be deemed revoked.
Front Setback from
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY' Side Street Setback from Center Line
I hereby affirm that there is'a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line
Lender's Name
Lender's Address FINAL DATE INSPECTOR
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct. Issued by: ,"Date""""'► Permit
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this.0'6ty to enter the above-
mentioned property for inspection purposes., / /.00 Validated by: '
Signature of applicant t-. •- r00:�,�'-
Mailing Address ! ` Validation:
City, State, Zip
' A44-23 _..2 .;2}6 290.19 Sl
HARD COPY Gni i ZS 33